Should paramedics administer ibuprofen rather than aspirin to a patient with suspected acute pericarditis in the pre‑hospital setting?

Paramedics Should NOT Administer Ibuprofen or Aspirin for Suspected Pericarditis in the Pre-Hospital Setting

Paramedics should provide only supportive care with intravenous analgesics (paracetamol or opiates) for suspected pericarditis and avoid both ibuprofen and aspirin until the diagnosis is confirmed and acute coronary syndrome is definitively ruled out. 1

Critical Diagnostic Challenge in the Pre-Hospital Setting

The fundamental problem is that pericarditis can mimic ST-elevation myocardial infarction (STEMI) on ECG, presenting with diffuse ST-segment elevation, and distinguishing between these two life-threatening conditions in the field is extremely difficult. 1

• Pericarditis shows diffuse ST elevation without reciprocal ST depression and may have PR segment depression, whereas STEMI typically shows regional ST elevation with reciprocal changes. 1
• It is critical to consider pericarditis in every patient in whom fibrinolysis is considered for presumed STEMI, because administering thrombolytics or antiplatelet agents to a patient with pericarditis (who may have pericardial effusion or early tamponade) can be catastrophic. 1
• The diagnosis of pericarditis cannot be confirmed in the pre-hospital setting because it requires echocardiography to detect pericardial effusion and laboratory markers of inflammation. 1

Why Neither Ibuprofen Nor Aspirin Should Be Given Pre-Hospital

Ibuprofen is Contraindicated

Ibuprofen should not be used because it blocks the antiplatelet effect of aspirin and can cause myocardial scar thinning and infarct expansion if the patient actually has acute MI. 1

• NSAIDs other than aspirin should not be administered and may be harmful in patients with suspected acute coronary syndrome. 1
• If the patient turns out to have ACS rather than pericarditis, ibuprofen administration would be directly harmful. 1

Aspirin Creates Diagnostic Confusion

While aspirin is the cornerstone of ACS treatment and also used for confirmed pericarditis, giving aspirin pre-hospital when pericarditis is suspected creates two problems:

1. If the patient actually has aortic dissection mimicking pericarditis, aspirin can cause fatal hemorrhagic complications including aortic rupture and cardiac tamponade. 2
2. Aspirin should be given as soon as possible to patients with suspected ACS 1, but the difficulty of distinguishing aortic dissection from acute coronary syndrome in the pre-hospital setting makes premature administration potentially catastrophic. 2

Recommended Pre-Hospital Management Algorithm

Step 1: Assess for High-Risk Features

• Check for fever >38°C, subacute onset, immunosuppression, trauma, anticoagulant use, signs of myopericarditis, severe pericardial effusion, or cardiac tamponade. 3
• Look for the clinical triad of hypotension, clear lung fields, and elevated jugular venous pressure, which suggests cardiac tamponade requiring urgent pericardiocentesis. 1

Step 2: Rule Out Aortic Dissection

• Apply the Aortic Dissection Detection (ADD) score: 1 point each for high-risk condition (Marfan syndrome), high-risk pain (abrupt, severe, ripping/tearing), or high-risk exam finding (pulse deficit, >20 mmHg BP differential, new aortic regurgitation murmur). 2
• If ADD score ≥1, withhold all antithrombotic therapy and transfer to a center with 24/7 aortic imaging and cardiac surgery. 2

Step 3: Provide Symptomatic Relief Only

• Administer intravenous paracetamol (acetaminophen) or opiates for pain relief during transport. 1
• Stable uncomplicated pericarditis does not need any specific anti-inflammatory management during pre-hospital transportation. 1

Step 4: Transfer to Appropriate Facility

• Transfer patients to emergency department, chest pain unit, or cardiology unit in facilities where echocardiography and pericardiocentesis are available. 1
• Patients with signs of tamponade require immediate transfer to centers equipped for urgent pericardiocentesis. 1

In-Hospital Treatment After Diagnosis Confirmation

Once pericarditis is confirmed by echocardiography and laboratory markers, and ACS is ruled out:

• High-dose aspirin (500-1,000 mg every 6-8 hours or 650 mg every 4-6 hours) becomes the first-line treatment. 1, 4, 5, 3
• Colchicine 0.5-0.6 mg once or twice daily for 3 months should be added to reduce symptoms and prevent recurrence. 1, 4, 5, 6
• Ibuprofen and other NSAIDs may be considered only after MI is definitively excluded, though they should not be used for extended periods due to risk of myocardial scar thinning. 1, 4, 5

Common Pitfalls to Avoid

• Never administer NSAIDs (including ibuprofen) or aspirin based solely on clinical suspicion of pericarditis without definitive imaging to exclude ACS, aortic dissection, or tamponade. 1, 2
• Do not delay transfer to obtain 12-lead ECG if tamponade is suspected—hemodynamic compromise requires immediate pericardiocentesis. 1
• Recognize that pericardial friction rub may be absent in up to 65% of cases, so its absence does not rule out pericarditis. 1
• Corticosteroids should be avoided in the acute setting as they increase risk of recurrence and, if MI is present, increase risk of myocardial rupture. 1, 7